Healthcare Provider Details

I. General information

NPI: 1770528507
Provider Name (Legal Business Name): ELIZABETH C. DYER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

IV. Provider business mailing address

455 SAINT MICHAELS DR
SANTA FE NM
87505-7601
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-5554
  • Fax: 505-946-3173
Mailing address:
  • Phone: 505-820-5554
  • Fax: 505-946-3173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR28511
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: